br Discussion Our case demonstrates feasibility for
Discussion Our case demonstrates feasibility for improvement in erythropoiesis in a patient with poor predictor of ESA/G-CSF response/growth factor refractory, low-risk MDS who was treated with sertraline for co-morbid depression. Within 100 days concurrent administration of sertraline, ESA and G-CSF, the patient experienced resolution of transfusion dependence. In addition, sensitivity to endogenous EPO was demonstrated with rise in hemoglobin by more than 4 points and fall in endogenous EPO levels from 449IU/L to 70.3IU/L. To the best of our knowledge, this is the first description of a potential therapeutic role for SSRIs in patients with MDS. MDS is clinically heterogeneous with a variable risk AML progression, an observation that can be partially explained by the underlying genetic heterogeneity among patients . Gene hcv protease inhibitor profiling of patients with early MDS has identified multiple derangements in cell signaling pathways, including immunoregulation, apoptosis, and chemokine secretion . Abnormal levels of pro-inflammatory cytokines such as IL-12, IL-7, IFN-γ, and RANTES have been observed in marrow samples from these patients. These changes were associated with an increased number of inflammatory CD3+ CD4+ Th17 cells, leading to amplification in marrow apoptotic signaling and resulting in ineffective hematopoiesis and eventual marrow failure . Similar imbalances in inflammatory cytokines underlie the pathophysiology of major depression. Recent work found higher levels of pro-inflammatory cytokines such as IL-2, IL-12, and TNF-α and lower levels of anti-inflammatory cytokines such as IL-4 in patients with major depressive disorder as compared to normal controls. An 8-week course of sertraline treatment resulted in an objective improvement in depression as well as normalization of many of the cytokine derangements . Serotonin is known to have diverse immunoregulatory actions including activation of helper T cells, enhancement of NK cell activity, and induction of B-cell proliferation; thus the anti-inflammatory effect of SSRI treatment are likely directly related to their modulation of inflammatory process. These effects of SSRI treatment have been explored in relation to other related disease processes, namely rheumatoid arthritis, a state of chronic inflammation. In a recent study, the use of sertraline showed a significant reduction in clinical arthritis in a mouse model accompanied by a measured decrease in TNF-α serum levels .
Conflict of interest
Introduction Common clinical manifestations of large granular lymphocyte leukemia (LGL leukemia) include cytopenias, recurrent infections, splenomegaly, and autoimmune disorders [1,2]. Diagnosis can be difficult, and is usually based on clinical presentation, persistent peripheral LGL lymphocytosis, and morphologic/immunophenotypic analysis . For T-LGL leukemia, a T-cell receptor (TCR) gene rearrangement study is performed to confirm the presence of the monoclonal T-cell population. Determining the clonality of NK-LGL cells is challenging. An abnormal killer-cell Ig-like inhibitory receptor (KIR) expression pattern has been reported in some of the NK-LGL leukemia patients, although this is not routinely employed . Chronic exposure to antigen or virus has been postulated to be the initial trigger in LGL leukemia pathogenesis [4,5]. Recent studies demonstrated that JAK/STAT pathway deregulation may promote clonal expansion of the activated LGL population [6,7]. To further understand LGL leukemia pathogenesis, we identified a patient with a distinct clinical course. The CDR3 sequences, TCRVβ profiles, STAT3 mutation profile and the underlying signaling pathway were examined throughout the disease.
Materials and methods The Institutional Review Board of Hershey Medical Center, Pennsylvania State University approved this study. The patient׳s peripheral blood mononuclear cells were collected between 2002 and 2013. For TCR deep sequencing, the TCR CDR3β regions were amplified and sequenced by Adaptive Biotechnologies Corp (Seattle, WA) using the ImmunoSEQ assay on cDNAs . Data was analyzed using the ImmunoSEQ analyzer toolset . Real-time quantitative PCR (qRT-PCR) was employed to examine the TCRVβ profile, using primers and methods described previously , except that SybrGreen (Life Technologies) was used and target specificity was confirmed within the IMGT primer database . Deep sequencing results for one clone were validated using PCR-based CDR3 sequencing with primers designed from the IMGT primer database (TBV9, 5′-CAC TCT GAA CTA AAC CTG A-3′; CB1A, 5′-GGG TGT GGG AGA TCC TG(C)-3′). Conventional Sanger STAT3 mutation testing was carried out as previously described by Koskela et al. . Primer pairs were designed to cover exons 20–21 encoding the STAT3 Src Homology 2 (SH2) domain [6,7]. Droplet digital PCR (ddPCR) assays were designed to detect individual mutations D661Y, Y640F and S614R. Assays were designed to the following context sequences: D661Y GGATATTGGTAGCAT(A/C)CATGATCTTATAGCC, Y640F AGCTGCTGCTTTGTG(A/T)ATGGTTCCACGGACT, and S614R GACGCCTCCTTCTTT(T/G)CTGCTTTCACTGAAT. Assays were performed in duplicate on the QX200 droplet reader and generator (Bio-Rad, Hercules, CA). Western immunoblotting utilized antibodies to STAT3 (#9139), pY705-STAT3 (#9131), MCL-1 (#5453) and GAPDH (#2118) (Cell Signaling, Danvers MA). Intensities of the protein bands were determined using ImageJ software .